Medicare Coverage and Documentation Requirements: The Fundamentals

1. The Medicare Home Health Benefit: What You Need to Know

Understanding who is eligible and what services are considered covered under the home health Medicare benefit is an important aspect for reimbursement in a home care agency. If care is provided to an ineligible patient or non-covered services are provided, your agency cannot bill for those services. This chapter will introduce the Medicare Benefits Policy Manual, Chapter 7- Home Health with a brief review of contents.

2. Effective Documentation to Support Medicare Eligibility Requirements

It is important to remember that Medicare is a medical insurance program. On every visit made to a Medicare beneficiary, the home care clinician must determine if the patient meets or continues to meet the eligibility requirements of the Medicare home health program. This includes determining if the patient requires reasonable and medically necessary services and is confined to the home (is homebound); determining if the services are provided under a plan of care established and approved by a physician; assuring the patient is under the care of a physician; determining if the patient requires intermittent skilled nursing care, physical therapy, or speech therapy, or if the patient has a continuing need for occupational therapy, as well as physician certification/recertification. This chapter will examine each of these requirements, utilizing the guidance from the Medicare Benefits Policy Manual and examples to illustrate the intent of each of these requirements and the required elements to document effectively.

3. Effective Documentation to Support Medicare Covered Services: Nursing Services

It is essential that every home care nurse and manager who cares for and/or supervises Medicare beneficiaries understand the services and coverage that Medicare reimburses, assuming all criteria are met and documentation supports covered care. As with all insurance products, there are covered and non-covered services. This chapter will discuss the 15 specific nursing services/skills with examples that are/may be covered, and the documentation required to support a reimbursable service. This information is housed in Chapter 7 of the Medicare Policy Manual, and this information should be the basis for care related to quality and coverage. Some of the fundamental tenets of what makes a service skilled will also be reviewed. It is important to note that just because it is a "coverable" service does not mean it will be covered. Clinicians in home care have an important responsibility to support covered care and services, and this is reflected in the clinical documentation.

4. Effective Documentation to Support Medicare Covered Services: Therapy Services-PT, SLP, and OT

This chapter will discuss the specific covered services/skills with examples that are/may be covered for each therapy discipline and the documentation required to support a reimbursable service.

5. Effective Documentation to Support Medicare Covered Services: Home Health Aide Services

This chapter will discuss the specific covered services/skills with examples that are/may be covered for home health aide services and the documentation required to support a reimbursable service.

6. Effective Documentation to Support Covered Services: Medical Social Services

This chapter will discuss the specific covered services/skills with examples that are/may be covered for Medical Social Services and the documentation required to support a reimbursable service.

7. Pulling it All Together: Tools for Effectively Reviewing Your Documentation with New Eyes

This Chapter will show a quick and easy checklist tool to ask questions to help clinicians and managers determine quality and medical necessity by reviewing components of the clinical record. The use of peer review of clinical records to improve the quality, detail, and individualization of the patient clinical records is discussed.